PracticeUpdate Dermatology February 2019

EDITOR’S PICKS 13

Utility of Laboratory Test Result Monitoring in Patients Taking Oral Terbinafine or Griseofulvin for Dermatophyte Infections JAMA Dermatology Take-home message • This study measured the rate of laboratory test abnormalities in 4985 healthy adults and children using terbinafine or griseof- ulvin for dermatophyte infections. Elevated ALT, AST, anemia, lymphopenia, and neutropenia were infrequent, and rates were comparable to the baseline rates. Most (93.4%) of the abnormalities that occurred were grade 1. The grade 2 or higher laboratory abnormalities detected with terbinafine consisted of 4 cases of ALT elevations (0.2%), 1 case of AST elevation (0.1%), 1 case of anemia (0.1%), and 5 cases of lymphopenia (0.7%). The rate of laboratory abnormalities for griseofulvin microsize was low, with 3 patients with grade 2 neutropenia (4%) and 1 patient with grade 2 lymphopenia (1%), all of whom continued the treatment course uneventfully. There was only 1 patient with a grade 1 AST elevation with griseofulvin ultra-microsize, and no cases of ALT measurement elevation, anemia, neutropenia, or lymphopenia were identified. • Given the low rates of abnormalities, routine interval laboratory test result monitoring appears to be unnecessary in healthy adults and children taking oral terbinafine or griseofulvin for dermatophyte infections. Caroline K. Crabtree MD

Abstract IMPORTANCE Terbinafine hydrochloride and griseofulvin are effective oral treatments for der- matophyte infections but have been associated with hepatic and hematologic abnormalities. The prevalence of alanine aminotransferase eleva- tions, aspartate aminotransferase elevations, anemia, lymphopenia, and neutropenia among adults and children taking terbinafine and gri- seofulvin is unclear. OBJECTIVE To measure the rate of laboratory test result abnormalities in healthy adults and children taking terbinafine or griseofulvin for dermatophyte infections. DESIGN, SETTING, AND PARTICIPANTS This retro- spective study assessed adults and children taking terbinafine or griseofulvin for derma- tophyte infections from January 1, 2006, to December 31, 2016. Data were collected from one Midwest health care system. Exclusion cri- teria were preceding diagnosis of hepatic or hematologic condition and preceding or con- current use of oral ketoconazole, amphotericin, or itraconazole. MAIN OUTCOMES AND MEASURES The rates of ele- vated alanine aminotransferase measurements, elevated aspartate aminotransferase measure- ments, anemia, lymphopenia, and neutropenia in adults and children taking terbinafine, griseof- ulvin microsize, or griseofulvin ultramicrosize were calculated. Secondary measures included rates of baseline abnormalities, frequency of laboratory test results that required additional testing or discontinued use of medication, and laboratory test result monitoring practices. RESULTS This study included laboratory data from 4985 patients (mean [SD] age, 42.8 [20.3] years; 2288 [45.9%] female) receiving 4309 courses of terbinafine, 634 courses of griseof- ulvin microsize, and 159 courses of griseofulvin ultramicrosize. We identified a low rate of labo- ratory test result abnormalities in patients taking

" …this study assists us in counseling patients and

Utility of Laboratory Test Result Monitoring in Patients Taking Oral Terbinafine or Griseofulvin for Dermatophyte Infections. JAMA Dermatol 2018 Oct 17;[EPub Ahead of Print], DA Stolmeier, HB Stratman, TJ McIntee, EJ Stratman. www.practiceupdate.com/c/74959 binafine. I think we all want to protect ourselves from malpractice suits, and the concept of defensive medicine can sometimes still be good medical practice; however, this study assists us in counseling patients and parents that good care does not have to be as invasive, especially for children. When I prescribe relatively short courses of terbinafine to children and adoles- cents, I offer blood work monitoring, telling them what my usual protocol is for adults, but give them the chance to decline it while explaining “my sense” that the risks of problems in children are less (and perhaps overrated in adults too)....and I document the conversation in my notes (my defense, if needed?). Almost all decline the offer to monitor. Now I have more data to support my clinical care and what constitutes good medical care. COMMENT By Eliot N. Mostow MD, MPH T his study was impressive in that it used data from 4985 patients receiving 4309 courses of ter-

parents that good care does not have to be as invasive, especially for children. "

terbinafine or griseofulvin. When laboratory test result abnormalities occurred, most were low grade (212 [93.4%] grade 1) and did not require subsequent laboratory test result evaluation or discontinued use of medication (15 051 [99.9%]). Elevations in alanine aminotransferase meas- urements were detected infrequently and were comparable to baseline detection rates (61 [3.5%] vs 95 [3.6%] for terbinafine, 2 [2.1%] vs 3 [3.7%] for griseofulvin microsize, and 0 vs 2 [5.0%] for griseofulvin ultramicrosize). Rates of elevated aspartate aminotransferase measure- ments, anemia, lymphopenia, and neutropenia were also infrequent and comparable to base- line rates. CONCLUSIONS AND RELEVANCE In this study. the rates of alanine aminotransferase elevations, aspartate aminotransferase elevations, ane- mia, lymphopenia, and neutropenia in adults and children taking terbinafine or griseoful- vin were low and equivalent to the baseline rates of abnormalities in this population. Rou- tine interval laboratory test result monitoring appears to be unnecessary in adults and chil- dren without underlying hepatic or hematologic conditions taking terbinafine or griseofulvin for dermatophyte infections. Abandoning frequent laboratory monitoring can decrease unneces- sary health care spending, decrease patient psychological angst associated with blood draws, and allow for expanded use of these effective oral medications.

VOL. 3 • NO. 1 • 2019